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Memulai dan

Intensifikasi Insulin

Makbul M Aman
DIABETES AND LIPID CENTRE RSUP. Dr. WAHIDIN SUDIROHUSODO
DEVISION ENDOCRINE AND METABOLISM DEPARTMENT OF INTERNAL MEDICINE
FACULTY OF MEDICINE HASANUDDIN UNIVERSITY /
RS. UNHAS
Tujuan Pembelajaran

 Memahami peran insulin dalam pengendalian


glukosa darah
 Meningkatkan kemampuan dalam memulai dan
mentitrasi dosis insulin, menggunakan insulin
basal dan premixed
 Mampu melakukan monitoring dan evaluasi
penggunaan insulin
Treatment therapies for Type 2 diabetes
When and How to start treatment

START TREATMENT OAD TREATMENT START INSULIN INSULIN INTENSIFICATION

+-other OAD Basal +


Lifestyle + Basal Insulin
or GLP-1 Bolus
Metformin Insulin Basal Plus
agonists Insulin

HbA1c ≥7.0%

Adapted from Raccah et al. Diabetes Metab Res Rev 2007;23:257. Slide 3
Insulin can be initiated anytime
• Traditionally, insulin had been reserved as the last line of therapy
• Considering the benefits of normal glycemic status,
insulin can be initiated earlier, as soon as is required.

Inadequate + + +
Lifestyle 1 OAD 2 OAD 3 OAD

Initiate Insulin

Indication 1. Fasting BG > 250 mg/dL


: 2. Random BG > 300 mg/dL
3. Hb A1c > 10 %
4. Weight loss ++
5. Ketonuria
Benefits of Insulin Therapy
1. Prevention of acute metabolic crises
2. Quick return to ‘health’
3. ↓ ↓ symptoms of glucosuria and hyperglycemia
4. Sense of well-being
5. Anabolic & anti–catabolic effects of insulin
6. Restoration of -cell function
7. -cell protection from apoptosis & preservation
8. Postponement of ‘Secretory Failure’
One of the greatest medical breakthroughs of the last
century.

5
Kapan Insulin Diperlukan?

• Penurunan berat badan secara drastis


• Hiperglikemia berat diikuti dengan ketosis
• Ketoasidosis Diabetes (KAD)
• Kondisi hiperglikemia Hiper Osmolar Non Ketotik (HONK)
• Hiperglikemia diikuti dengan laktat asidosis
• Kegagalan kombinasi OAD dengan dosis optimal
• Infeksi sistemik, pembedahan mayor, Miokardiak Infark Akut,
stroke
• Gestational DM dengan kadar gula darah yang tidak
terkendali dengan diet.
• Kerusakan berat fungsi ginjal dan hati
• Kontraindikasi dan/atau hipersensitivitas terhadap OAD

PERKENI Consensus Guidelines, 2011.


Hambatan dalam inisiasi insulin

Masalah klinis Masalah pasien


Klinisi mengkhawatirkan kondisi Takut suntikan / jarum
hipoglikemia, kenaikan berat badan

Takut hipoglikemia
Kesalahpahaman bahwa peningkatan Menganggap insulin sebagai tanda
insulin meningkatkan risiko kegagalan pasien pribadi untuk
kardiovaskular mengendalikan penyakit

Rumit dan labor-intensive Rumit dan labor-intensive


Kurangnya pengetahuan/pengalaman Mahal
Tidak cukup waktu untuk edukasi Takut kualitas hidup menurun
pasien
Keuangan
Teknis (buta dan hidup sendiri)
Type of Insulin

Insulin

Analog Human

Rapid Premixed
Long Short Inter
Acting Acting Acting mediate
Insulin di Indonesia

Mula
Jenis Insulin Puncak Durasi Kemasan
Kerja
Insulin Prandial (Berhubungan dengan makanan)

Insulin Kerja Pendek

Regular (Actrapid®, 30-60 120-180 Vial,


Humulin® R) 5-8 jam
menit menit Pen/Cartridge

Insulin Analog Kerja Singkat


Insulin Lispro (Humalog®) 5-15 menit 30-90 menit 3-5 jam Pen/Cartridge
Insulin Glulisine (Apidra®) 5-15 menit 30-90 menit 3-5 jam Pen
Insulin Aspart (Novorapid®) 5-15 menit 30-90 menit 3-5 jam Pen, Vial

PERKENI Consensus, 2011.


Insulin di Indonesia (lanjutan)

Jenis Insulin Mula Kerja Puncak Durasi Kemasan

Insulin Kerja Menengah


Vial,
NPH (Insulatard®, Humulin® N) 2-4 jam 4-10 jam 10-16 jam
Pen/Cartridge
Insulin Kerja Panjang
Tanpa
Insulin Glargine (Lantus®) 2-4 jam 20-24 jam Pen
Puncak
Tanpa
Insulin Detemir (Levemir®) 2-4 jam 16-24 jam Pen
Puncak

Insulin Campuran

70% NPH 30% Regular


30-60 menit Ganda 10-16 jam Pen/Cartridge
(Mixtard®, Humulin® 30/70)
70% Insulin Aspart Protamin
10-20 menit Ganda 15-18 jam Pen
30% Insulin Aspart (Novomix® 30)
75% Insulin Lispro Protamin
25% Insulin Lispro (HumalogMix® 5-15 menit Ganda 16-18 jam Pen/Cartridge
25)

PERKENI Consensus, 2011.


Profil Jenis-Jenis Insulin

RAPID-ACTING: Aspart, glulisine, lispro 4–5 hours

Plasma
insulin Regular 6–8 hours
levels NPH 12–20 hours
LONG-ACTING:
Glargine 24 hours
Detemir 20 hours

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hours
Mekanisme kerja Insulin
Glucose
Insulin

Insulin
receptor

PPARg
RXR
Synthesis GLUT 4
mRNA

PPRE transcription

promoter Coding reg

Modified from Howard L. Foyt et al. Thiazolidinediones. Diabetes Mellitus: a Fundamental and Clinical Text, 2nd Ed.
Goal of Insulin Therapy

We are trying to duplicate


(mimic) how the pancreas
works in releasing insulin
for someone who doesn’t
have diabetes
Ideally

• Insulin administration should mimic nature


• Natures way is basal insulin 24 hrs. a day
• And bolus insulin with every feeding
• Insulin lispro, asparte or glulisine can supply
bolus
• Insulin glargine or detemir can supply the
basal with one injection per day
• Control of blood sugar will prevent the
complications of diabetes
Mimicking Nature With Insulin
Basal/Bolus Concept
Physiologic Insulin Secretion
24-hr profile
50
(µU/mL)
Insulin

25  Suppresses glucose production


between meals and overnight
0 Basal insulin
 Nearly constant levels
B L D
 50% of daily needs
150
Glucose
(mg/dL)

100

50
Basal glucose
0
7 8 91011121 2 3 4 5 6 7 8 9
AM
Time of Day PM
Adapted with permission from Bergenstal RM et al. In: DeGroot LJ, Jameson JL, eds. Endocrinology.
4th ed. Philadelphia, Pa: WB Saunders Co.; 2001:821
The Basal/Bolus Insulin Concept
• Basal Insulin
– Suppresses glucose production between meals
and overnight non-food related insulin needs.
– 50% of daily needs
• Bolus Insulin (Mealtime or Prandial)
– The amount of insulin required to cover the
food you eat.
– Limits hyperglycemia after meals
– Immediate rise and sharp peak at 1 hour
– 10% to 20% of total daily insulin requirement at
each meal
Basal/Bolus Treatment Program with
Rapid-acting and Long-acting Analogs

Breakfast Lunch Dinner


Aspart, Aspart, Aspart,
Lispro Lispro Lispro
Plasma insulin

Glulisine Glulisine Glulisine

Glargine

4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00


Time
How Do We Define Insulin Intensification?

INITIATE Starting insulin therapy

Dose titration to ensure that the patient


OPTIMISE receives the maximum benefit from the
prescribed treatment

Modification of the insulin regimen,


INTENSIFY e.g. adding to or changing the therapy in order
to maintain glycaemic control
Memulai dan mentitrasi Insulin Basal

Malam hari atau Pagi hari Insulin kerja


panjang ATAU
Malam Insulin kerja menengah Mulai dg insulin basal suntikan
tunggal,
Dosis harian: 10 U atau 0.2 U/kg
contohnya insulin glargine
Cek
GDP perhari
Jika terjadi hipoglikemia atau
Naikkan dosis 2 U per 3 hari sampai GDP
GDP <3.9 mmol/L (<70 mg/dL),
3.9–7.2 mmol/L (70–130 mg/dL)
Kurangi dosis insulin di malam
Jika GDP >10 mmol/L (>180 mg/dL), hari ≥4 unit, atau 10% jika >60
Naikkan dosis 4 U per 3 hari unit

Lanjutkan regimen dan


cek HbA1c tiap 3 bulan
Nathan DM et al. Diabetes Care 2009;32:193-203.
Penyesuaian dosis Insulin
menurut ADA
• Jika A1C tidak tercapai setelah 2-3 bulan pengobatan dan GDP
masih dlm rentang target, tambahkan suntikan sesuai kadar gula
darah sebelum makan (pre-meal)

– GD pre-meal makan siang yg meningkat: Tambahkan insulin


rapid-acting saat makan pagi
– GD pre-meal makan malam yg meningkat: Tambahkan
insulin rapid-acting saat makan siang*
– GD sebelum tidur yg meningkat: Tambahkan insulin rapid-
acting saat makan malam

• Premixed insulin tidak dianjurkan pd penyesuaian dosis; namun


dapat digunakan sebelum makan pagi dan/atau makan malam
jika proporsi kerja singkat-menengah nya sama dg proporsi
campuran yg tersedia
Nathan DM et al. Diabetes Care 2006;29:1963-72.
Penyesuaian dosis Insulin
menurut ADA

Periksa kembali glukosa darah sebelum makan


untuk melihat apakah diperlukan suntikan lagi.
Jika A1C tetap tidak tercapai, cek glukosa darah 2
jam setelah makan dan sesuaikan dengan insulin
kerja singkat

Nathan DM et al. Diabetes Care 2006;29:1963-72.


Intensifikasi Insulin

• Basal Plus dan Basal Bolus


– Ketika Insulin basal ditambahkan pd obat oral tidak
mencapai target A1C
– Lakukan langkah-langkah penambahan insulin
(Stepwise) dg insulin mealtime
• Basal +1 — suntikan kedua sebelum largest meal
• Basal +2 — suntikan ketiga sebelum 2nd meal
• Basal +3 — suntikan keempat sebelum 3rd meal

PERKENI Consensus, 2011.


Langkah-langkah pendekatan
pengobatan DMT2
A1C <7.0% Basal
Glukosa plasma sebelum makan 70–130 mg/dl Bolus
Puncak glukosa plasma setelah makan <180 mg/dl Basal
ADA-2012 Basal +
Basal Plus
3 suntikan
Plus 2 suntikan prandial
prandial utk
1 suntikan asupan
Insulin Basal prandial utk glukosa
asupan terbesar
Sehari 1x glukosa
OAD (sampai optimal) terbesar
Monoterapi
atau
kombinasi
Diet dan
olahraga A1C A1C tdk terkendali, GDP sesuai target
Tdk terkendali GDPP>8.8 mmol/l (>160 mg/dl)

Waktu

Konsensus PERKENI 2011 ; Raccah D. Diabetes Ob Met 2008;10:76-82.


Management of Hyperglycemia in Type 2 Diabetes:
A Consensus Algorithm for the Initiation
and Adjustment of Therapy

A Consensus Statement from the American Diabetes


Association (ADA) and the European Association for the
Study of Diabetes (EASD)
Version 1: August 2006

Version 2: January 2008

Version 3: January 2009


Initiating and Adjusting Insulin
Hypoglycemia Bedtime intermediate-acting insulin, or
or FG >3.89 mmol/l (70 mg/dl): bedtime or morning long-acting insulin
Reduce bedtime dose by ≥4 units (initiate with 10 units or 0.2 units per kg) Target range:
(or 10% if dose >60 units) Check FG and increase dose until in target range. 3.89-7.22 mmol/L
(70-130 mg/dL)

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)

Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin

Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.


Step One…
Hypoglycemia
Bedtime intermediate-acting insulin, or
or FG >3.89 mmol/l (70 mg/dl): bedtime or morning long-acting insulin
Reduce bedtime dose by ≥4 units (initiate with 10 units or 0.2 units per kg)
(or 10% if dose >60 units)
Check FG and increase dose until in target range.

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)

Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin

Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.


Step One: Initiating Insulin
• Start with either…
– Bedtime intermediate-acting insulin or
– Bedtime or morning long-acting insulin

Insulin regimens should be designed taking


lifestyle and meal schedules into account

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.


Step One: Initiating Insulin, cont’d
• Check fasting glucose and increase dose until in
target range
Target range: 70-130 mg/dl
• Typical dose increase is 2 units every 3 days, but if
fasting glucose >180 mg/dl), can increase by large
increments (e.g., 4 units every 3 days)
• If hypoglycemia occurs or if fasting glucose <70
mg/dl
Reduce bedtime dose by ≥4 units or 10%
if dose >60 units

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.


After 2-3 Months…
• If HbA1c is <7%...
– Continue regimen and check HbA1c every 3
months

• If HbA1c is ≥7%...
– Move to Step Two…

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.


Step Two…
Hypoglycemia Bedtime intermediate-acting insulin, or
or FG >3.89 mmol/l (70 mg/dl): bedtime or morning long-acting insulin
Reduce bedtime dose by ≥4 units (initiate with 10 units or 0.2 units per kg) Target range:
(or 10% if dose >60 units) Check FG and increase dose until in target range. 3.89-7.22 mmol/L
(70-130 mg/dL)

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)

Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin

Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.


Step Two: Intensifying Insulin
If fasting blood glucose levels are in target range but HbA1c
≥7%, check blood glucose before lunch, dinner, and bed and
add a second injection:
– If pre-lunch blood glucose is out of range, add
rapid-acting insulin at breakfast
– If pre-dinner blood glucose is out of range, add
NPH insulin at breakfast or rapid-acting insulin at
lunch
– If pre-bed blood glucose is out of range, add
rapid-acting insulin at dinner

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.


Making Adjustments

• Can usually begin with ~4 units and adjust by 2


units every 3 days until blood glucose is in
range

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.


After 2-3 Months…
• If HbA1c is <7%...
– Continue regimen and check HbA1c every
3 months

• If HbA1c is ≥7%...
– Move to Step Three…

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.


Step Three…
Hypoglycemia Bedtime intermediate-acting insulin, or
or FG >3.89 mmol/l (70 mg/dl): bedtime or morning long-acting insulin
Reduce bedtime dose by ≥4 units (initiate with 10 units or 0.2 units per kg) Target range:
(or 10% if dose >60 units) Check FG and increase dose until in target range. 3.89-7.22 mmol/L
(70-130 mg/dL)

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)

Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner

If HbA1c ≤7%... If HbA1c 7%...

Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin

Nathan DM et al. Diabetes Care. 2006;29(8):1963-72.


Step Three:
Further Intensifying Insulin
• Recheck pre-meal blood glucose and if out of
range, may need to add a third injection

• If HbA1c is still ≥ 7%
– Check 2-hr postprandial levels
– Adjust preprandial rapid-acting insulin

Nathan DM et al. Diabetes Care 2006;29(8):1963-72.


Understand the basal bolus regimen
Bedtime intermediate acting insulin, or bedtime or
morning long acting insulin
(initiate with 10 units or 0.2 units per kg)
Check FG and increase dose until in target range

If HbA1c < 7% If HbA1c ≥ 7%

If FBG in target range, check BG before lunch, dinner, and bed.


Continue regimen; check Depending on BG Results, add second injection
HbA1c every 3 months (can usually begin with ~4 units and adjust by 2 units every 3 days
until BG in range)

Pre-dinner BG out of range: add NPH


Pre-lunch BG out of range: add Pre-bed BG out of range: add
insulin at breakfast or rapid-acting
rapid-acting insulin at breakfast rapid-acting insulin at dinner
insulin at lunch

If HbA1c < 7% If HbA1c ≥ 7%

Continue regimen; Recheck pre-meal BG level and if out of range, may need to add another injection; if HbA1c
check HbA1c every 3 continues to be out of range, check 2-hr postprandial levels and adjust preprandial rapid-acting
months insulin
Mengatasi Hambatan Insulin

Hambatan Intervensi
“Sekali memulai insulin Sarankan untuk mencoba dalam kurun
maka saya tidak pernah waktu tertentu (contoh: 1 bulan),
menghentikannya” kemudian dievaluasi kembali
“Saya belum Insulin bukan suatu hukuman; edukasi
menyelesaikan pasien mengenai progresivitas penyakit
pekerjaan dengan baik” diabetes
“Insulin dapat membuat Edukasi pasien mengenai progresivitas
kebutaan” penyakit diabetes

“Saya takut suntikan” Pertimbangkan insulin pen

Polonsky W et al. Clin Diabetes 2004;22:147-50.


Insulin dan Waktu Pemeriksaan Gula
Darah Mandiri
Monitoring Gula
Insulin Waktu suntikan Pemberian
Darah

1-2 jam setelah suntikan


Kerja sebelum atau
Setelah makan atau segera sebelum
Singkat setelah makan
makan
Diantara makan/makan Segera sebelum makan
Regular Sebelum makan berikutnya atau pada saat berikutnya; biasanya 1-2
akan tidur jam setelah suntikan

Sebelum sarapan, Diantara makan siang/malam Sebelum sarapan,


Kerja Diantara tengah sebelum tidur, midsleep,
Sebelum makan
Meneng
ah malam, malam/sarapan, dan sarapan, sebelum
pada saat akan tidur Diantara pukul 04:00/sarapan sarapan
Sebelum sarapan,
Kerja Kebanyakan pada malam
atau pada saat akan Sebelum sarapan
Panjang hari
tidur

Medical Management of Type 2 Diabetes. 7th Edition. American Diabetes Association, 2012.
Pilihan untuk Follow-Up Pasien

• Saat kunjungan / kontrol

• feedback: SMS, social media

• Pasien sendiri yg menyesuaikan

• Follow-up harus sesuai dg kondisi tertentu spt


budaya, ketersediaan teknologi dll

Hirsch IB et al. Clin Diabetes 2005;23:78-86.


Take home points on Insulin Rx

• Start Insulin earlier


• Best option if A1C >8.5 despite oral therapy
• Glargine /Lantus (Basal insulin) added to oral
medications a safe and effective way to initiate
• Titrate to effect, if still not controlled, go to Basal
Plus Strategy  multiple daily injections
• Basal bolus is an ideal treatment option, since
provide optimal A1C control but has a limitation
as 4 times injection daily
SoloStar ®

Thank you
Contoh Kasus

Pendahuluan
Tn M, usia 50 tahun, suku jawa, memiliki diabetes sudah 4
tahun. Saat ini tidak ada keluhan, namun khawatir dengan
gula darahnya yg tak terkendali. Pada pemeriksaan fisik
TD 130/80 mmHg, Tinggi 167 cm, Berat. Hasil lab terakhir
GDP 210 mg/dl, 2JPP 455 mg/dl, dan A1C 9.5%.

Pasien sdh mengatur makanannya sesuai saran ahli gizi,


dan berolahraga 2x seminggu. Obat yg diminum
glimepiride 1x4mg, metformin 3x500mg, dan selama 2
tahun terakhir,sitagliptin 1x100mg.
Contoh Kasus

Diskusi
• Bagaimana status kesehatan Tn.M?
• Bagaimana manajemen selanjutnya pada pasien
ini?
• Kapan sebaiknya kita memulai insulin?
Contoh Kasus

Diputuskan akan memulai insulin.

Diskusi
• Insulin jenis apa yang akan disarankan pada pasien ?
• Dimulai pada dosis berapa?
• Bagaimana menyesuaikan dosis insulin jika
diperlukan?
• Materi edukasi apa saja yang perlu diberikan pada
pasien?
Contoh Kasus

Tn M kembali
Tn M gula darahnya sdh terkendali selama 6 bulan dengan basal
insulin glargin 14 U sebelum tidur, glimepirid 1x4mg, metformin
3x500mg, namun beberapa minggu lalu gula darahnya naik lagi. A1C
sekarang 9,5%. Berikut hasil glukosa darahnya :

Sebelum Sebelum
Hari Catatan
sarapan makan malam
Minggu 120 285
Senin 160 305 Dosis Glargine ditingkatkan 2 U
Selasa 130 190
Rabu 165 276 Lupa menyuntik Glargine
Kamis 120 289
Jumat 110 233
Sabtu - 312
Contoh Kasus

Diskusi
• Sebutkan masalah dari Tn.M?
• Bagaimana saran anda untuk manajemen
selanjutnya?
• Bagaimana saran anda untuk penggunaan insulin
selanjutnya?
• Bagaimana penyesuaian dosis insulin yang anda
sarankan?
Contoh Kasus

Follow-up
•Tiga bulan kemudian Tn.M kembali. A1C sekarang 8,7%. Obatnya
glimepiride 1x4 mg, metformin 3x500mg, glargin 1x14 U sebelum tidur,
glulisine 8 U sebelum makan malam, Gula darahnnya kemudian:

Sebelum Sebelum
Hari Sebelum sarapn Catatan
makan siang makan malam
Minggu 110 190 160
Senin 108 205 154
Selasa 120 198 160
Rabu 115 212 152
Kamis 98 200 170
Jumat 108 180 156
Sabtu 99 190 160
Contoh Kasus

Diskusi
• Bagaiman status Tn.M?
• Bagaimana saran anda selanjutnya dalam penggunaan
insulin?
Contoh Kasus

6 bulan kemudian …

Tn M gula darahnya sudah terkendali dengan glulisine


8 U sebelum makan pagi, 8 U sebelum makan siang,
dan 8 U sebelum makan malam, ditambah glargine 14
U sebelum tidur, dan metformin3x 500mg. Pasien
menanyakan kemungkinan untuk menggunakan
insulin yg lebih sederhana.
Contoh Kasus

Pertanyaan
• Apa yg akan anda sarankan?
• Jika anda menyarankan insulin campuran,
bagaimana anda menyesuaikan dosis nya?